The Affordable Care Act and the Poor

March 23, 2011
Guest Post

By Sara Rosenbaum, Hirsh Professor of Health Law and Policy and chair of the Department of Health Policy at The George Washington University School of Public Health and Health Service. This post is part of an ACSblog symposium marking the one-year anniversary of the Affordable Care Act.   
Viewed in its broadest perspective, the Affordable Care Act (ACA) represents two landmark achievements in U.S. health policy: a sweeping reform of the private market for health insurance; and a decisive shift of national resources toward families and individuals who, by virtue of poverty, illness, or both, historically have been barred from health care.

Through a series of bold adjustments in existing policies, the ACA essentially reinvents the private health insurance market, transforming it over time into a social good whose regulation is essential to the public's health and the means by which a nation assures that its population can obtain necessary health care. The principal elements of this transformation consist of a ban on exclusion and discrimination based on health status or pre-existing health condition, the obligation to adhere to principles of guaranteed issue and renewal, and the insertion of safeguards that will ensure that, once covered, individuals will have access to necessary care without regard to artificial annual or lifetime expenditure caps.

In the individual and small group markets, the historic epicenter of discrimination against the sick, the Act redefines coverage itself to encompass "essential health benefits" expressed in terms of both covered benefit classes and limits on cost-sharing. Most remarkably, perhaps, where the content of coverage is concerned, the Act defines essential health benefits to include habilitative treatments for persons with developmental disabilities. It is this benefit, whose traditional exclusion from private insurance products, represents the central means by which the market has denied beneficial care to a patient population that counts among the nation's most vulnerable.

The Act's provisions addressing health care for low-income, medically vulnerable and medically underserved Americans are no less seminal. Health reform remakes Medicaid, perhaps the single most important conceptual and operational pillar of the American health care system, because of its historic role in absorbing health care costs shunned by the private market and even by Medicare itself. Medicaid's achievements in this regard can fairly be said to be virtually immeasurable. For nearly 50 years, Medicaid has been the primary source of investments that markets traditionally seek to avoid: in the poor, in populations that carry high social and health risks; and both directly and indirectly, in a primary care and hospital infrastructure for medically underserved communities and populations.

In eliminating the last vestige of its welfare roots - its denial of coverage for non-pregnant working age adults without minor children - the ACA elevates Medicaid to the level of a true insurer of the poor and underserved. In so doing, the Act not only rectifies a historic inequity in U.S. social welfare policy but also alleviates an enormous source of financial risk for the private health insurance industry and the more affluent individual and group customers who buy its products.

Had the ACA stopped with the Medicaid reforms that open the doors to health insurance coverage for an additional 16 million people, its achievement would have been a historic. But the law goes further. By 2019 the ACA will provide financial subsidies for an estimated 19 million low and moderate income individuals and for some 4 million small businesses. Furthermore, the ACA will double the nation's community health centers, which over nearly a half century, have become a central mainstay of the nation's primary care policy and the health care anchor for some 23 million patients as of 2010.

Finally, it is a testament to the belief that a nation's health policy should be guided by the concepts of equity and social justice that the Act makes no fewer than 15 express references to the reduction of disparities in health and health care as a stated national goal. These references appear throughout the law, in its numerous provisions aimed at achieving greater investment in the public's health and the health workforce, and in its provisions aimed at reforming the way in which the health care system itself is organized, financed, delivered, and its quality, measured.

It should hardly be surprising that the Act has encountered such a deep political and legal backlash. Enactment of a health reform law grounded in basic principles of equity at a time of such enormous political, economic, and social strife will stand as one of the most momentous acts of governance ever witnessed in the United States. To focus on whether all of the elements of the Affordable Care Act survive completely intact or go through further metamorphosis is to miss its deeper point. With its passage, the nation has gained a deeper understanding of the elements that together comprise a more just health care system, and when all is said and done there really is no retreating from this fuller vision.